Abstract Cesarean section (CS) is currently used at over twice the rate recommended by the World Health Organization (CDC, 2006);use of the procedure has almost doubled in the last two decades for reasons that are as yet poorly understood. Overutilization results in avoidable morbidity and mortality and higher health costs related to childbirth. Many causes for the increased use of CS have been suggested, including growth in the number of "maternal requests" -- healthy women asking for CS in the absence of medical indications. An NIH expert panel explored maternal request CS and concluded that at this time there is insufficient evidence to warrant CS on maternal demand without medical indications and recommended "increased research devoted to strategies to predict and influence the likelihood of successful vaginal birth" (NIH, 2006, p. 20). Using the same data, the American College of Obstetrics and Gynecologists (ACOG) concluded that there is no reason to deny a surgical birth to a healthy mother as long as she is well-informed (ACOG, 2003). The divergence between these positions points to a critical gap in knowledge about the factors that drive CS rates, including the influence of maternal demand on the use of CS. Despite this recent focus on maternal demand, there is scant research on what women want from their birthing experience, including their reasons for choosing one mode of childbirth over another. The purpose of our proposed research is to answer the question: what factors influence women's decisions about how their babies will be born? Women's hopes and desires for their first birth experience are influenced by what they know - both consciously and unconsciously. Because people are only partly aware of the attitudes and beliefs that inform their hopes and desires, this proposal will use three methods of data collection. The first is a projective method commonly used in the social sciences to access knowledge that exists outside of consciousness. The second is a focus group method that provides a venue for birthing women to articulate the conscious basis for their ideas about childbirth and allow participants to compare their ideas with others. Third, all women will be interviewed after the baby is born to build understanding about how their experiences influence future birthing choices the women make. Participants will be 50 primigravid women with uncomplicated pregnancies aged 21 or older. This proposal builds on the researchers'previous work related to the use of CS. It is one step in a defined program of research directed towards improving the health of mothers and their children by optimizing care during pregnancy, labor and birth. PUBLIC HEALTH RELEVANCE: This project in focused on building knowledge about what women want from their birthing experience and what informs their choices about mode of birth. This knowledge is essential if we are to understand the role of maternal demand in use of CS. Our data will inform public health policy concerned with both supporting maternal choice and ensuring long term maternal- child health by reducing the risks associated with childbirth. This study is part of a systematic program of research dedicated to improving women's health and satisfaction with their birthing experience.